Microsurgical ligation of spinal arteriovenous fistulae: techniques

Spinal dural arteriovenous fistula (SDAVF) is a rare vascular malformation of the spine. Only a limited number of cases of SDAVF have been reported in the current literature. We describe the case of a 74 year old male who presented with gradually progressive bilateral lower extremity weakness and bladder dysfunction and was subsequently diagnosed with SDAVF affecting both the thoracic and lumbar spine. The patient later underwent embolization with some improvement in his neurologic symptoms.

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A Septuagenarian With Progressive Lower Extremity Weakness and Pain

10.1093/med/9780197583425.003.0077 ◽

2021 ◽

pp. 235-237

Author(s):

Nicholas L. Zalewski

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Lower Extremity ◽

Arteriovenous Fistula ◽

Digital Subtraction Angiography ◽

Dural Arteriovenous Fistula ◽

Digital Subtraction ◽

Resonance Imaging ◽

Spinal Dural Arteriovenous Fistula ◽

Lower Extremity Weakness

A 75-year-old man was referred for evaluation of treatment-resistant transverse myelitis. His medical history included hypertension, coronary artery disease, benign prostatic hyperplasia, and chronic kidney disease. Eight years earlier, the patient noted development of radiating pain down the left lower extremity during long drives, lower extremity weakness and pain, on the left greater than right. He received epidural lumbar corticosteroid injections. Nine months before the current evaluation, his symptoms became refractory, and he underwent surgical decompression with laminectomy at L3-L5. This provided substantial relief for the lower extremity pain. Review of outside magnetic resonance imaging indicated multilevel lumbar stenosis before his surgery and possible, faint, T2-hyperintense cord signal extending into the conus. At the time his symptoms worsened, magnetic resonance imaging of the thoracic spine showed longitudinally extensive T2 hyperintensity extending from the thoracic cord into the conus without contrast enhancement. Evaluation in our department included cerebrospinal fluid analysis, which showed an increased protein concentration of 92 mg/dL, 1 total nucleated cell/µL, normal immunoglobulin G index, and no supernumerary oligoclonal bands. Magnetic resonance angiography of the spinal canal showed mild prominence of vascularity at T10-T12 but no clear spinal dural arteriovenous fistula. However, given the strong suspicion for spinal dural arteriovenous fistula in an older man with progressive myelopathy worsening with corticosteroids, longitudinally extensive lesion extending into the conus, and no evidence of inflammation, spinal digital subtraction angiography was performed. The spinal digital subtraction angiography confirmed the diagnosis of left spinal dural arteriovenous fistula at T11. A T11-12 laminectomy and ligation of the spinal dural arteriovenous fistula was successfully performed without complication. The patient followed up with his local providers for rehabilitation. Spinal dural arteriovenous fistula is the most common spinal arteriovenous malformation, arising from an acquired abnormal connection between a radicular artery and radiculomedullary vein. Progressive congestion and cord edema lead to neurologic deficits over time. Cases are commonly seen in older men with a history of back surgery or trauma. A delay in diagnosis of 1 to 3 years is common.

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Microsurgical Management of a Spinal Dural Arteriovenous Fistula With Shared Blood Supply to the Artery of Adamkiewicz: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy293 ◽

2018 ◽

Vol 16 (6) ◽

pp. E174-E175 ◽

Cited By ~ 1

Author(s):

C Michael Cawley ◽

Brian M Howard ◽

Daniel L Barrow

Keyword(s):

Spinal Cord ◽

Lower Extremity ◽

Arteriovenous Fistula ◽

Blood Supply ◽

Dural Arteriovenous Fistula ◽

Spinal Cord Infarction ◽

Thoracic Myelopathy ◽

Spinal Dural Arteriovenous Fistula ◽

Lower Extremity Weakness ◽

Artery Of Adamkiewicz

Abstract The presented case is of a 65-yr-old gentleman referred for thoracic myelopathy. He developed bilateral, nondermatomal foot dysesthesia 14 mo prior to presentation, which progressed to numbness below the L3 level. He reported progressive gait instability, bilateral lower extremity weakness, and required a cane for ambulation. He subsequently developed urinary incontinence, while bowel function was spared. The neurological examination upon presentation revealed lower extremity strength was reduced to 4/5 in all major muscle groups bilaterally, while sensation and proprioception were reduced below the L3 level. Patellar and Achilles reflexes were not elicited and clonus was absent. Gait was unsteady and slow. The patient was not able to perform heel, toe and tandem gait. MRI revealed abnormal T2 hyper-intense signal and spinal cord expansion from T6 through the conus medullaris. Angiography revealed a dural arteriovenous fistula (dAVF) originating from the left T9 radicomedullary pedicle, which also supplied the Artery of Adamkiewicz (AoA). The patient underwent T8-10 laminectomies. Prior to disconnection of the fistula, an aneurysm clip was applied to the fistulous point and an indocyanine green video angiogram was completed to show that the fistula no longer opacified, but that the AoA remained patent, which was later confirmed with angiography. As of discharge, the patient's motor exam had improved substantially, though his sensory deficits persisted. This case demonstrates that surgical disconnection is requisite in the treatment of spinal dAVF that have a shared blood supply with the AoA, as embolization risks spinal cord infarction. The patient consented to presentation of this case in a de-identified fashion.

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Surgical correction of a spinal arteriovenous fistula with an unusual presentation

Neurosurgical FOCUS ◽

10.3171/2012.v2.focus12145 ◽

2012 ◽

Vol 33 (Suppl1) ◽

pp. 1

Author(s):

Aaron Cohen-Gadol

Keyword(s):

Arteriovenous Fistula ◽

Nerve Root ◽

Cervical Spinal Cord ◽

Cervical Lesions ◽

Spinal Dural Arteriovenous Fistula ◽

Spinal Arteriovenous Fistula ◽

Clinical Presentations ◽

Wide Range ◽

Brainstem Dysfunction ◽

Microsurgical Techniques

Spinal dural arteriovenous fistula (dAVF) is an acquired abnormal arterial-to-venous connection within the spinal dura with a wide range of clinical presentations and natural history. Spinal dAVF occurs when a radicular artery makes a direct anomalous shunt with a radicular vein within the dura of the nerve root sleeve. Cervical dAVF is a rare entity as the majority of spinal dAVFs present within the thoracolumbar segment with myelopathy. Only a small number of cervical lesions have been described, and only one presented with brainstem dysfunction. Herein we present one patient with brainstem dysfunction secondary to a spinal dAVF. The fistula was located within the C-3 nerve root sleeve. The details of microsurgical techniques to disconnect the fistula will be discussed. Although the option of endovascular disconnection of the fistula is reasonable, the author elected to proceed with microsurgical disconnection after discussion regarding the risks of such an endovascular route for the cervical spinal cord. The video can be found here: http://youtu.be/t8rUnZ8qVfY.

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Spinal Dural Arteriovenous Fistula: Diagnosis and Treatment

Neurologico Spinale Medico Chirurgico ◽

10.15562/nsmc.v1i2.75 ◽

2018 ◽

Vol 1 (2) ◽

Author(s):

Nur Setiawan Suroto

Keyword(s):

Spinal Cord ◽

Arteriovenous Fistula ◽

Vascular Malformation ◽

Dural Arteriovenous Fistula ◽

Motor Symptoms ◽

Elderly Men ◽

Spinal Dural Arteriovenous Fistula ◽

Sensory Disturbances ◽

Av Fistulas ◽

Low Rate

Spinal dural arteriovenous (AV) fistulas are the most commonly encountered vascular malformation of the spinal cord and a treatable cause for progressive paraplegia or tetraplegia. They most commonly affected are elderly men and are classically found in the thoracolumbar region.Symptoms gradually progress or decline in a stepwise manner and are commonly associated with pain and sphincter disturbances. Surgical or endovascular disconnection of the fistula has a high success rate with a low rate of morbidity. Motor symptoms are most likely to improve after treatment, followed by sensory disturbances, and lastly sphincter disturbances.

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Dural arteriovenous fistulas presenting with brainstem dysfunction: diagnosis and surgical treatment

Neurosurgical FOCUS ◽

10.3171/2012.2.focus1217 ◽

2012 ◽

Vol 32 (5) ◽

pp. E10 ◽

Cited By ~ 14

Author(s):

Charles Kulwin ◽

Bradley N. Bohnstedt ◽

John A. Scott ◽

Aaron Cohen-Gadol

Keyword(s):

Dural Arteriovenous Fistula ◽

Venous Drainage ◽

Craniocervical Junction ◽

Rare Entity ◽

Arteriovenous Fistulas ◽

Drainage Patterns ◽

Clinical Presentations ◽

Wide Range ◽

Brainstem Dysfunction ◽

Dural Arteriovenous Fistulas

A cerebral dural arteriovenous fistula (DAVF) is an acquired abnormal arterial-to-venous connection within the leaves of the intracranial dura with a wide range of clinical presentations and natural history. The Cognard classification correlates venous drainage patterns with neurological course, identifying 5 DAVF types with increasing rates of symptomatic presentation. A spinal DAVF occurs when a radicular artery makes a direct anomalous shunt with a radicular vein within the dural leaflets of the nerve root sleeve. A cervical DAVF is a rare entity, as most spinal DAVFs present as thoracolumbar lesions with myelopathy. In this paper the authors present 2 patients presenting initially with brainstem dysfunction rather than myelopathy secondary to craniocervical DAVF. The literature is then reviewed for similar rare aggressive DAVFs at the craniocervical junction presenting with brainstem symptomatology.

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Balloon-assisted transarterial embolization of type 1 spinal dural arteriovenous fistula

Neurosurgical FOCUS ◽

10.3171/2014.v2.focus14175 ◽

2014 ◽

Vol 37 (v1supplement) ◽

pp. 1

Author(s):

Brian Lee ◽

Vivek A. Mehta ◽

William J. Mack ◽

Matthew S. Tenser ◽

Arun P. Amar

Keyword(s):

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Vascular Malformations ◽

Transarterial Embolization ◽

Mri Imaging ◽

Spinal Dural Arteriovenous Fistula ◽

Lower Extremity Weakness ◽

Segmental Artery ◽

Spinal Vascular Malformations

Type 1 spinal dural arteriovenous fistula (dAVF) constitute the vast majority of all spinal vascular malformations. Here we present the case of a 71-year-old male with progressive myelopathy, lower-extremity weakness and numbness, and urinary incontinence. MRI imaging of the thoracic spine demonstrated cord edema, and catheter spinal angiography confirmed a type 1 spinal dAVF. The fistula was supplied by small dural branches of the left L-2 segmental artery. Angiographic cure was achieved with a one-stage procedure in which coils were used to occlude the distal segmental vessels, followed by balloon-assisted embolization with Onyx.The video can be found here: http://youtu.be/8aehJbueH0U.

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СLINICAL ASPECTS, DIAGNOSTICS AND MICROSURGICAL TREATMENT OF SPINAL DURAL ARTERIOVENOUS FISTULAS (LECTURE)

Russian journal of neurosurgery ◽

10.17650/1683-3295-2019-21-2-53-65 ◽

2019 ◽

Vol 21 (2) ◽

pp. 53-65

Author(s):

G. Yu. Evzikov ◽

V. А. Parfenov ◽

А. V. Farafontov ◽

P. V. Kuchuk ◽

S. А. Kondrashin ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Spinal Dural Arteriovenous Fistula ◽

Microsurgical Treatment ◽

Arteriovenous Fistulas ◽

Wide Range ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

The lecture is dedicated to spinal dural arteriovenous fistula – infrequent disorder which not well known among wide range of neurosurgeons. The findings on etiology, clinic and treatment are presented.

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Mimicking Amyotrophic Lateral Sclerosis: A Case of a Spinal Dural Arteriovenous Fistula

Case Reports in Neurology ◽

10.1159/000521030 ◽

2021 ◽

pp. 802-806

Author(s):

Mónica Santos ◽

Sofia Reimão ◽

Mamede de Carvalho

Keyword(s):

Spinal Cord ◽

Amyotrophic Lateral Sclerosis ◽

Arteriovenous Fistula ◽

Vascular Malformation ◽

Dural Arteriovenous Fistula ◽

Venous Hypertension ◽

Lower Limbs ◽

Spinal Dural Arteriovenous Fistula ◽

Conventional Angiography ◽

Lateral Sclerosis

A number of conditions can mimic amyotrophic lateral sclerosis (ALS), which are in general excluded by neurophysiological and neuroimaging investigation. We present a novel mimicking disorder. A 58-year-old male, without relevant past medical history, presented with a 7-year history of progressive paraparesis. On examination, he had bilateral thigh atrophy, fasciculations, and asymmetric paraparesis (severe on the left side). Upper motor neuron signs were present in the lower limbs, with normal sensory examination. Needle EMG disclosed mild chronic neurogenic changes in the lower limbs. Brain and spinal cord neuroimaging was normal, namely, in the dorso-lumbar segment. Lumbar puncture showed mild hyperproteinorachia. Diagnosis of slowly progressive (possible) ALS was established. One year later, he required a bilateral support to walk, and neurological examination revealed weak tendon reflexes, abnormal pinprick, and proprioceptive sensation in the legs. Repeated lumbar MRI showed an extensive spinal cord oedema from T7 to the conus with multiple perimedullary vessel flow voids suggestive of a vascular malformation. Conventional angiography revealed a spinal dural arteriovenous fistula in L2–L3 with the left L4 lumbar branch as the afferent artery. Dural arteriovenous fistula is the most common vascular malformation of the spinal cord, despite being rare. It leads to arterialization of spinal veins, causing venous hypertension, spinal cord oedema, and ischaemia. The clinical picture includes a stepwise, sometimes fluctuant, myeloradiculopathy. In this case, EMG changes did not meet Awaji criteria. This case reinforces the need to critically follow atypical cases to ascertain clinical progression in patients with suspected ALS.

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Outcome after the Treatment of Spinal Dural Arteriovenous Fistulae: A Contemporary Single-institution Series and Meta-analysis

Neurosurgery ◽

10.1227/01.neu.0000126878.95006.0f ◽

2004 ◽

Vol 55 (1) ◽

pp. 77-88 ◽

Cited By ~ 179

Author(s):

Michael P. Steinmetz ◽

Michael M. Chow ◽

Ajit A. Krishnaney ◽

Doreen Andrews-Hinders ◽

Edward C. Benzel ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Retrospective Review ◽

Initial Treatment ◽

Dural Arteriovenous Fistula ◽

Meta Analysis ◽

Type I ◽

Single Institution ◽

Spinal Dural Arteriovenous Fistula ◽

Arteriovenous Fistulae

Abstract OBJECTIVE: Spinal dural arteriovenous fistulae (Type I spinal AVMs) are the most common type of spinal vascular malformations. The optimal treatment strategy has yet to be defined, and endovascular embolization is being offered with increasing frequency. A 7-year single-institution retrospective review of outcome with surgical management of Type I spinal AVMs is presented along with a meta-analysis of existing literature. METHODS: For the institutional analysis, a retrospective review of all patients who underwent treatment at our institution for Type I spinal AVMs was performed. Between 1995 and the present (the time frame during which endovascular treatments were available), 19 consecutive patients were treated. Follow-up was performed by clinical examination or telephone interview, and functional status was measured by use of the Aminoff-Logue score. For the meta-analysis, a MEDLINE search between 1966 and the present was performed for surgical, endovascular, or combined treatment of spinal dural arteriovenous fistula. These series were included in a meta-analysis to evaluate success and failure rates, complications, and functional outcome. Specifically, embolization and microsurgery were compared. RESULTS: For the institutional analysis, 18 of 19 patients were available for long-term follow-up after surgery. There were no surgical failures, but one complication was seen. Patients demonstrated a statistically significant improvement in gait and bladder function after surgery. For the meta-analysis, 98% of those patients treated with microsurgery had their dural arteriovenous fistulae successfully obliterated after the initial treatment, compared with only 46% with embolization, as judged by radiographic or clinical follow-up. 89% percent of patients demonstrated improvement or stabilization in neurological symptoms after surgical treatment. Few complications were demonstrated with either surgery or embolization. CONCLUSION: At this point, surgery seems to be superior to embolization for the management of spinal dural arteriovenous fistula. The fistula is usually obliterated after the initial treatment, with few clinical or radiographic recurrences. The majority of patients either improve or stabilize after treatment. Few worsen, and the morbidity is minimal. It is reasonable to attempt initial embolization, especially at the time of the initial diagnostic spinal angiogram. The treating physicians and patients should be aware of the high chance of recurrence, and patients may ultimately require surgery or repeat embolization. After endovascular therapy, patients are committed to repeat angiography and probably embolization. For these reasons, it is the authors' opinion that surgery should be used as the first-line therapy for spinal dural arteriovenous fistulae.

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